West Volusia Family and Sports Medicine
Dear Valued Patient,

We are pleased that you have chosen to partner with us in the care for your health. However, in order to insure that you receive the best care possible and are taken care of in the most efficient way, we ask that you review the following office policies.

Healthcare Compliance:

  • We ask that you make an effort to comply with the physician's recommendations regarding routine follow-ups, medications, specialist referrals, procedures and etc.

Pain Management:

  • Please note that a referral will be made to a pain management specialist for chronic pain management medication at the discretion of Dr. Hill.

Prescriptions:

  • Prior to your office visits, please make a note of any refill needed.
  • For refills we ask that you contact your pharmacy and have them fax us a refill request, allowing 24-48 hours for it to be processed and forwarded back to the pharmacy.
  • Mail-Order prescriptions can be called in to the office and then picked up from the front desk. We no longer fax prescriptions to mail-order pharmacies. Again please allow 24 to 48 hours for processing.
  • Prescriptions for controlled substances cannot be called in or faxed to the pharmacy, but can be picked up at the front desk or at your scheduled appointment.

Lab/Imaging/Sleep study Follow up Policy:

  • To go over any results for labs, imagining or sleep studies you will need to make an appointment. If no appointment is made and there are abnormal results we will contact you to make an appointment to go over the results.

Cancellations/ No Show policy:

  • Time has been specifically reserved for your physician appointment, procedure or treatment. Please call at least 24 hours ahead to cancel your appointment. There will be a $25 charge if you fail to show up for a scheduled appointment or cancel with less than 24 hours' notice.

I hereby expressly acknowledge the receipt of West Volusia Family and Sports Medicine's Notice of Privacy Practices.

Patient Information

Name
Date of Birth
Social Security Number
Mailing Address
Email Address
City
State
Zip
Home Telephone Number
Mobile Telephone Number
Marital Status
Male   
Female

Primary Policy Holder

Name
Date of Birth
Social Security Number
Mailing Address
City
State
Zip
Telephone Number
Marital Status
Relationship to Patient
Male   
Female

Primary Insurance

Name
ID#
Group#

Secondary Insurance

Name
ID#
Group#
Policy Holder
Relationship to Patient

Employment Information

Employer
Phone
Occupation

Emergency Contact/Notification of Kin - Someone not in household

Name
Relationship to Patient
Telephone Number

Dr. John Hill and/or staff may discuss my medical conditions with the following people:

Name
Relationship to Patient
Telephone Number
Name
Relationship to Patient
Telephone Number
Name
Relationship to Patient
Telephone Number

Release of Information / Assignment of Benefits

I authorize the release of any medical information necessary to process my insurance claim. I authorize and request payment of medical benefits directly to my physicians. I agree that this authorization will cover all medical services rendered until such authorization is revoked by me; I understand and agree that regardless of my insurance status I am responsible for any balance of my account.

I Agree

Health History Questionnaire

All questions contained in this questionnaire are protected by privacy acts under HIPAA and will become part of your medical record. Fill in the blanks or check appropriate answers.

Personal Health History

Childhood Illnesses:

Measles
Mumps
Rubella
Chickenpox
Rheumatic Fever
Polio

Vaccination History

Tetanus or TET/DIP
Influenza
Hepatitis (series of 3)
Pneumonia
MMR (Measles, Mumps, Rubella)
Chickenpox/Shingles

List any medical problems that other doctors have diagnosed or check applicable items on list.

High Blood Pressure
Hypothyroidism
Diabetes II
COPD
Peripheral Vascular
Heart Disease
High Cholesterol
Atrial Fibrillation
Asthma
Arthritis

Surgeries and procedures (Please fill in any that applies):

Carotid Endartectomy ( remove plaque from neck vessels)
Thyroidectomy
Cardiac Catheterization. Stent
Coronary Artery Bypass: # of Vessels:
Pacemaker Automatic Implanted Defibrillator
Aortic Aneurysm Repair
Vascular Bypass: Specify Location:
Breast Surgery: Mastectomy Lumpectomy Biopsy (non-cancer)
Chest Surgery
Kidney Surgery
Hip Replacement: Left Right
Knee Replacement: Left Right
Amputations:
Endoscopy of Esophagus/ Stomach/ Duodenum (EGD)
Cholecystectomy (Gallbladder Removed)
Colonoscopy: Finding: Polyps Diverticulosis IBS Crohn's
Gastric Bypass: Type:
Appendectomy
Hysterectomy: Abnormal Vaginal (this is uterus only, see below)
Ovaries and Tubes: Left Right
Tubal Ligation (sterilization)
Bladder: Specify what type:
Prostate: TUNA TURP Other:
Cataracts: Left Right
Plastic Surgery: Specify:
Other:
Other:

Testing in the last two years:

CT (Computed Tomography): Head Chest Abdomen Pelvis
MRI: Head Chest Abdomen Pelvis
DEXA Bone Scan for Bone Mass
Nuclear Medicine Scan

Hospitalizations Within The Last 2 Years

Date
Reason
Hospital
Date
Reason
Hospital
Date
Reason
Hospital
Have you ever had a blood transfusion? Yes   No
If yes, what year?
Have you ever had radiation therapy? Yes   No
If yes, indicate reason:
Have you ever had a blood clot in your lungs or legs? Yes   No
If yes, what year?

Allergies or intolerance to Medications?

Please list the drug and make sure you are specific about your reaction. List your prescribed drugs and over-thecounter drugs, such as vitamins and inhalers, eye drops and nasal sprays.

Name the Drug (BRAND and Generic)
Reaction You Had
Name the Drug (BRAND and Generic)
Reaction You Had
Name the Drug (BRAND and Generic)
Reaction You Had

Current Medications:

Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?
Name the Drug (BRAND and Generic)
Strength/Dose/Form
How and when do you take the medication?

HEALTH HABITS AND PERSONAL SAFETY

ALL QUESTIONS IN THIS SECTION ARE OPTIONAL AND WILL BE CONFIDENTIAL IN COMPLIANCE WITH PRIVACY POLICIES

The Amount of exercise you get on a weekly basis . Please check the appropriate answer.

Sedentary (No Exercise)
Mild Exercise (Climb stairs, walk 3 block, golf)
Occasional Vigorous Exercise (Work or recreation, less the 4x / week for 30 min.)
Regular Vigorous exercise (Work or recreation, 4x / week or more for 30 min.)

How many caffeinated drinks do you consume?

None Coffee Cola Tea Other
Number of cups/cans per day?


Do you consume alcoholic beverages? Please answer questions to the best of your ability .

None Beer Wine Mixed Drinks Coolers Other
How many servings per week?
Have you ever experienced blackouts? Yes No
Have you ever experienced blackouts? Yes No
Have you considered stopping? Yes No
Are you prone to binge drink? Yes No
Do you drive after drinking? Yes No

Do you now or have you ever smoked or chewed tobacco? Fill in the blanks

I smoke cigarettes: packs per day for: years.
I quit in: , I smoked: packs per day for years.
Chew-#/Day
Cigars-#/Day
Pipe-#/Day
Are you interested in quitting? Yes No

Personal questions related to your sexual health.

Are you sexually active? Yes No
Are you or your wife trying to get pregnant? Yes No
If not, how are you preventing pregnancy?
Any discomfort with intercourse such as pain or dryness? Yes No
Any problems with frequency or loss of interest in intercourse? Yes No


Questions about your health and safety.

Do you live alone? Yes No
Do you have frequent falls? Yes No
Do you wear glasses, contacts, hearing aid or dentures? Yes No

Questions about your wishes.

Do you have an Advance Directives or Living Will? If Yes, please furnish a copy for your record. Yes No
If you do not, would you like information on the preparations on these? If yes please ask out staff or check our website. Yes No
Have you designated a Healthcare Surrogate? If yes, please furnish a copy of your designation for your records. Yes No
Are you an Organ Donor? Yes No

Family Health History

Father
Age (present or at death)
Health Problems
Mother
Age (present or at death)
Health Problems
Sibling
Age (present or at death)
Health Problems
Sibling
Age (present or at death)
Health Problems
Sibling
Age (present or at death)
Health Problems
Sibling
Age (present or at death)
Health Problems
Child
Age (present or at death)
Health Problems
Child
Age (present or at death)
Health Problems
Child
Age (present or at death)
Health Problems
Child
Age (present or at death)
Health Problems
Grandmother (Maternal)
Age (present or at death)
Health Problems
Grandfather (Maternal)
Age (present or at death)
Health Problems
Grandmother (Paternal)
Age (present or at death)
Health Problems
Grandfather (Paternal)
Age (present or at death)
Health Problems

Women Only

How old were you when you started menstruating?
Date of last menstruation:
How many pregnancies?
How many live births?
Are you pregnant or breastfeeding?
Yes   
No
Have you had a urinary tract, bladder, or kidney infections with in the last year?
Yes   
No
Do you have problems with control of urination?
Yes   
No
Have you had any blood in your urine?
Yes   
No
Any hot flashes or sweating at night?
Yes   
No
Date of last pap and rectal exam?
Date of last Mammogram?
Have you had any of the following infections? Abnormal PAP    HPV    Herpes    HIV    Chlamydia    Gonorrhea

Men Only

Do you usually get up to urinate during the night?
Yes   
No
If yes, how many times?
Do you feel pain or burning with urination?
Yes   
No
Have you had any blood in your urine?
Yes   
No
Do you feel burning discharge from penis?
Yes   
No
Has the force of your urination decreased?
Yes   
No
Have you had any kidney, bladder, or prostate infections within the last 12 months?
Yes   
No
Do you have hesitancy in starting urination?
Yes   
No
Have you had any of the following infections? HPV    Herpes    HIV    Chlamydia    Gonorrhea
Do you have problems emptying your bladder completely?
Yes   
No
Any difficulty with erection or ejaculation?
Yes   
No
Any testicle pain or swelling?
Yes   
No
Date of last prostate and rectal exam:

Reason for visit or any health concerns/ additional information:

Family, Significant others, and friends. Under certain circumstances, we may disclose PHI (Protected Health Information) to family members, other relatives, or close personal friends or others that you identify to improve communication of relevant information (most commonly laboratory results, prescription issues and or changes, appointment scheduling. etc.) to their involvement in your care or payment related to your care; or to notify them of your location, general condition, or death.

In compliance with this office's HIPAA policy, I am authorizing West Volusia Family & Sports Medicine's staff to release PHI as necessary to support and assist in my care. Please list each individual authorized to receive information as stated above and provide us with the information requested.

Please indicate if you wish to have your personal health care information released to your spouse, children, or significant other below:

Person 1:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:

I authorize the release of my PHI to this person.
Person 2:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:

I authorize the release of my PHI to this person.
Person 3:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:

I authorize the release of my PHI to this person.
Person 4:
Name:
Relationship:
Address:
City:
State:
Zip:
Phone:

I authorize the release of my PHI to this person.

I understand that checking this box and typing my name below constitutes a legal signature.
SIGNATURE
Relationship to Patient

© Dr. John Hill MD
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